cancer de seno metastasico

VOLUME 29 ⅐ NUMBER 9 ⅐ MARCH 20 2011

JOURNAL OF CLINICAL ONCOLOGY A S C O S P E C I A L A R T I C L E

American Society of Clinical Oncology Executive Summary
of the Clinical Practice Guideline Update on the Role of
Bone-Modifying Agents in Metastatic Breast Cancer
Catherine H. Van Poznak, Sarah Temin, Gary C. Yee, Nora A. Janjan, William E. Barlow, J. Sybil Biermann,
Linda D. Bosserman, Cindy Geoghegan, Bruce E. Hillner, Richard L. Theriault, Dan S. Zuckerman,
and Jamie H. Von Roenn
From the University of Michigan, Ann
Arbor, MI; American Society of Clinical A B S T R A C T
Oncology, Alexandria; Virginia Common-
wealth University, Richmond, VA; Univer- Purpose
sity of Nebraska Medical Center, Omaha, To update the recommendations on the role of bone-modifying agents in the prevention and
NE; Cancer Research and Biostatistics, treatment of skeletal-related events (SREs) for patients with metastatic breast cancer with
Seattle, WA; Wilshire Oncology Medical bone metastases.
Group, Rancho Cucamonga, CA; Y-ME
National Breast Cancer Organization; Lurie Methods
Comp Cancer Center of Northwestern A literature search using MEDLINE and the Cochrane Collaboration Library identified relevant
University, Chicago, IL; National Center for studies published between January 2003 and November 2010. The primary outcomes of interest
Policy Analysis, Dallas; The University of were SREs and time to SRE. Secondary outcomes included adverse events and pain. An Update
Texas MD Anderson Cancer Center, Hous- Committee reviewed the literature and re-evaluated previous recommendations.
ton, TX; and Mountain States Tumor Insti-
tute, Boise, ID. Results
Submitted September 3, 2010; accepted
Recommendations were modified to include a new agent. A recommendation regarding osteo-
January 13, 2011; published online ahead necrosis of the jaw was added.
of print at www.jco.org on February 22,
Recommendations
2011.
Bone-modifying agent therapy is only recommended for patients with breast cancer with evidence
Board Approved: December 2, 2010. of bone metastases; denosumab 120 mg subcutaneously every 4 weeks, intravenous pamidro-
Editor’s Note: This represents a brief nate 90 mg over no less than 2 hours, or zoledronic acid 4 mg over no less than 15 minutes every
summary overview of the complete Ameri- 3 to 4 weeks is recommended. There is insufficient evidence to demonstrate greater efficacy of
can Society of Clinical Oncology (ASCO) one bone-modifying agent over another. In patients with a calculated serum creatinine clearance
Clinical Practice Guideline Update and of more than 60 mg/min, no change in dosage, infusion time, or interval of bisphosphonate
provides the updated recommendations
administration is required. Serum creatinine should be monitored before each dose. All patients
with brief discussions of the relevant litera-
ture for each. The complete guideline,
should receive a dental examination and appropriate preventive dentistry before bone-modifying
which includes comprehensive discussions agent therapy and maintain optimal oral health. Current standards of care for cancer bone pain
of the literature, methodology information, management should be applied at the onset of pain, in concert with the initiation of bone-
and all cited references, plus a data supple- modifying agent therapy. The use of biochemical markers to monitor bone-modifying agent use is
ment with evidence tables the Update not recommended.
Committee used to formulate these
recommendations, are available at
www.asco.org/guidelines/bisphosbreast. bone-modifying agents as adjuvant treatment of
INTRODUCTION
Corresponding author: American Society of breast cancer and in managing treatment-associated
Clinical Oncology, 2318 Mill Rd, Suite 800,
The American Society of Clinical Oncology (ASCO) bone loss. Please note that the term bisphosphonate
Alexandria, VA 22314; e-mail: guidelines@
asco.org. first published evidence-based clinical practice in specific recommendations used in 2003 (Recom-
© 2011 by American Society of Clinical guidelines for use of bisphosphonates in breast can- mendations 1, 2, 4, 6, and 7) has been changed to the
Oncology cer in 2000.1a ASCO previously updated these guide- term bone-modifying agent.
0732-183X/11/2909-1221/$20.00 lines on bisphosphonates in breast cancer in 2003.1b
DOI: 10.1200/JCO.2010.32.5209 Reflecting the Update Committee’s recognition of Update Type
new types of agents, including osteoclast inhibitors This guideline is an update. This type of update
such as denosumab, and others that may be available is one in which a systematic review found some new
for future updates of this guideline, this guideline evidence and, consequently, some recommenda-
uses the term bone-modifying agents. tions were changed or added.1c The majority of the
As a result of changes in the field, the scope of recommendations are the same as in the 2003 guide-
this guideline has been narrowed to the use of lines for metastatic breast cancer. No additional data
bone-modifying agents for patients with metastatic are available with regard to the dose, dose interval, or
breast cancer. A separate update will cover the role of duration of therapy of bone-modifying agents. The

© 2011 by American Society of Clinical Oncology 1221
Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission.
Copyright © 2011 American Society of Clinical Oncology. All rights reserved.

Van Poznak et al

current guideline has added a recommendation regarding osteo- the English-language literature from January 2003 to July 15, 2009,
necrosis of the jaw (ONJ), a condition recognized after the devel- were conducted to address each of the original guideline questions;
opment of the 2003 guidelines. This guideline on metastatic breast subsequently, additional searches on adverse events were conducted.
cancer also reviews data on a new bone-modifying agent, deno- An additional search for randomized controlled trials (RCTs) reporting
sumab. There are new data on the bisphosphonate ibandronate. efficacy and case-control or cohort studies on adverse events published
However, the US Food and Drug Administration (FDA) has not between July 2009 and November 2010 was conducted. Specific num-
approved ibandronate for use in patients with breast cancer meta- bers of studies found in the literature search, the literature search terms,
static to the bone at the time of publication. For each of the and a QUORUM diagram are available online in the guideline and
recommendations, clinical judgment should also take into consid- Data Supplements 4 and 5 at www.asco.org/guidelines/bisphosbreast.
eration the patient’s general performance status, patient prefer-
ences, and overall prognosis. Inclusion/Exclusion Criteria
Articles were selected for inclusion if they met the following
METHODOLOGY criteria: participants had metastatic breast cancer and were randomly
assigned to receive a bone-modifying agent or placebo or an alterna-
This guideline was reviewed and approved by the Journal of Clinical tive intervention. Outcome measures for efficacy and adverse event
Oncology and the ASCO Clinical Practice Guidelines Committee and studies included at least one of the following: skeletal-related events
the Board of Directors. (SREs) and time to SRE, adverse events, pain, and quality of life (see
Definition of Terms). Searches for efficacy outcomes were limited to
Literature Search Strategy published phase III RCTs, systematic reviews, and meta-analyses. For
For this guideline, computerized literature searches of MEDLINE adverse events, the search was broadened to include case-control and
and the Cochrane Collaboration Library were conducted. Searches of cohort studies.

THE BOTTOM LINE

ASCO GUIDELINE UPDATE

The Role of Bone-Modifying Agents (BMAs) in Metastatic Breast Cancer

Intervention
● Bone-modifying agents (BMAs), including bisphosphonates

Target Audience
● Medical Oncologists, Radiation Oncologists, Surgical Oncologists, Palliative Care Providers

Key Recommendations
● BMAs are recommended for patients with metastatic breast cancer with evidence of bone destruction.
● Denosumab 120 mg subcutaneously every 4 weeks; intravenous (IV) pamidronate 90 mg over no less than 2 hours every 3 to 4
weeks; or IV zoledronic acid 4 mg over no less than 15 minutes every 3 to 4 weeks
● One BMA is not recommended over another.
● In patients with creatinine clearance Ͼ 60 mL/min, no change in dosage, infusion time, or interval is required; monitor creatinine
level with each intravenous bisphosphonate dose.
● In patients with creatinine clearance Ͻ 30 mL/min or on dialysis who may be treated with denosumab, close monitoring for hy-
pocalcemia is recommended.
● All patients should have a dental examination and preventive dentistry before using a BMA.
● At onset of cancer bone pain, provide standard of care for pain management and start BMAs.
● Use of biochemical markers to monitor BMA use is not recommended for routine care.

Methods
● Systematic review of medical literature and analysis of the medical literature by the Update Committee of an Expert Panel

Additional Information
● The recommendations, clinical questions, and a brief summary of the literature and discussion are in this Executive Summary.

The full guideline, with comprehensive discussions of the literature, methodology, full reference list, evidence tables, and clinical tools
and resources, can be found at www.asco.org/guidelines/bisphosbreast.

1222 © 2011 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY

Breast Cancer Bone-Modifying Agents Update Executive Summary

Definition of Terms skeletal morbidity period rate. Both the IV and oral formulations of
Most clinical trials define an SRE as fracture (pathologic, verte- ibandronate are approved for use in this setting in some countries
bral, and/or nonvertebral), radiation therapy to bone, surgery to bone, outside the United States.
and spinal cord compression. The definition may or may not include The guideline reviews data on a new agent, denosumab, a fully
hypercalcemia of malignancy. human monoclonal antibody to receptor activator of nuclear factor-
Skeletal morbidity period rate is the number of 12-week periods ␬-␤ ligand. Because ibandronate is not approved by the FDA, the
with new skeletal complications, divided by the total observational recommendation did not change to specify its use. There are no new
time. Skeletal morbidity rate is the number of SREs per year. Multiple- reports on clodronate in the metastatic bone disease setting.
event analysis is an analysis of data on all clinically relevant SREs and
time to each event. Clinical Question 2
What is the role of bone-modifying agents in the presence of
Guideline Policy extraskeletal metastases without evidence of bone metastases?
This Executive Summary for physicians is an abridged summary Literature update and discussion. This recommendation remains
of an ASCO௡ practice guideline. The practice guideline and this sum- unchanged from 2003. There have been no new clinical trials reported
mary are not intended to substitute for the independent professional with patients with breast cancer with extraskeletal metastases but who
judgment of the treating physician. Practice guidelines do not account do not have evidence of bone metastases.
for individual variation among patients and may not reflect the most
recent evidence. This summary does not recommend any particular Clinical Question 3A
product or course of medical treatment. Use of the practice guideline and What are the renal safety concerns of bone-modifying
this summary is voluntary. The full practice guideline and additional agent therapy?
information are available at www.asco.org/guidelines/bisphosbreast. Literature update and discussion. Pamidronate and zoledronic
acid are associated with renal deterioration, particularly in patients
Guidelines and Conflict of Interest with pre-existing renal impairment and in those who receive multiple
The Update Committee was assembled in accordance with cycles of bisphosphonate therapy. This recommendation was changed
ASCO’s Conflict of Interest Management Procedures for Clinical to reflect the new dosing guidelines for patients with pre-existing renal
Practice Guidelines (“Procedures,” summarized at www.asco.org/ impairment added to the zoledronic acid package insert in January
guidelinescoi). Members of the Update Committee completed AS- 200512 and the availability of the new bone-modifying agent, deno-
CO’s disclosure form, which requires disclosure of financial and other sumab. The zoledronic acid package insert recommends a lower initial
interests that are relevant to the subject matter of the guideline, includ- zoledronic acid dose (ranging from 3.0 to 3.5 mg) depending on the
ing relationships with commercial entities that are reasonably likely to estimated creatinine clearance. No similar dosing guideline exists for
experience direct regulatory or commercial impact as the result of pamidronate. The FDA-approved label for denosumab does not spec-
promulgation of the guideline. Categories for disclosure include em- ify a need for dose adjustment for renal safety.13
ployment relationships, consulting arrangements, stock ownership, In addition to the package inserts for denosumab, zoledronic
honoraria, research funding, and expert testimony. In accordance acid, and pamidronate, the evidence reviewed for this recommenda-
with the Procedures, the majority of the members of the Update tion included four RCTs, a safety extension of one of those RCTs, and
Committee did not disclose any such relationships. a retrospective cohort study.
Pamidronate and zoledronic acid should be withheld from pa-
tients developing renal deterioration as defined in the package inserts.
RESULTS Once serum creatinine returns to within 10% of baseline, therapy can
be resumed. The FDA label states that zoledronic acid therapy should
Table 1 lists the recommendations from the 2003 guideline and the be reinitiated at the same dose as that before treatment interruption.
2011 guideline update. Ibandronate may have a different renal safety profile than pamidro-
nate and zoledronic acid; however, no definitive conclusions about
Clinical Question 1 their comparative safety can be reached. Data on the long-term renal
What are the indications for using bone-modifying agents to safety of bone-modifying agents are limited.
reduce the risk of SREs in patients with metastatic breast cancer? When The Update Committee agrees with the FDA package insert di-
is the best time to initiate treatment with bone-modifying agents? rections for use of denosumab, pamidronate, and zoledronic acid,
Literature update and discussion. This recommendation was including the monitoring of laboratory parameters, dose, and infusion
changed from 2003 because of the results of trials of a new bone- times. The Update Committee encourages health care providers to be
modifying agent. The studies reviewed for this guideline were phase II active in reporting postmarketing safety concerns and to review the
trials, phase III trials, and follow-up studies of phase III clinical trial FDA labeling and Web sites for updates.
results on denosumab (two phase II trials2,3 and one phase III trial4), Follow-up from the zoledronic acid versus pamidronate studies
ibandronate (two phase III trials/analyses of oral ibandronate5,6 and have not changed the 2003 guideline’s conclusion that the safety of the
two phase III trials of intravenous [IV] ibandronate7,8), pamidronate two agents seems to be similar with respect to nonrenal adverse events.
(in the follow-up studies of the phase III zoledronic acid trial9,10 and as Ibandronate may have a slightly higher risk of GI adverse effects than
a comparator in two phase II trials2,3), and zoledronic acid (two zoledronic acid or placebo and higher arthralgia than placebo. Deno-
follow-up studies of a phase III trial9,10 and two new RCTs4,11). These sumab had a lower rate of arthralgia, asthenia, and acute-phase reac-
trials found that all four agents reduce SREs, the time to SRE, and tions than zoledronic acid and a higher rate of hypocalcemia. Patients

www.jco.org © 2011 by American Society of Clinical Oncology 1223

Van Poznak et al

Table 1. Summary of 2011 Recommendations
Recommendation Category 2003 Recommendations 2011 Recommendations Change

Recommendation 1: For breast cancer patients who have evidence of bone For patients with breast cancer who have evidence of bone metastases, Addition of new bone-modifying agent.
Indications and time destruction on plain radiographs, IV pamidronate 90 denosumab 120 mg subcutaneously every 4 weeks, IV Term changed from bisphosphonates
of initiation mg delivered over 2 hours or zoledronic acid 4 mg pamidronate 90 mg delivered over no less than 2 hours, or zoledronic to bone-modifying agents.
over 15 minutes every 3 to 4 weeks is acid 4 mg over no less than 15 minutes every 3 to 4 weeks is
recommended. Starting bisphosphonates in women recommended. Starting bone-modifying agents in women with an
with an abnormal bone scan and an abnormal CT or abnormal bone scan and an abnormal CT scan or MRI showing bone
MRI scan showing bone destruction, but normal destruction, but normal plain radiographs, is considered reasonable by
plain radiographs, is considered reasonable by Panel consensus based on the findings in women with lytic or mixed
Panel consensus based on the findings in women lytic/blastic changes on plain radiographs. Starting bone-modifying
with lytic or mixed lytic/blastic changes on plain agents in women with only an abnormal bone scan but without
radiographs. There is insufficient evidence relating evidence of bone destruction on radiographs, CT scans, or MRI is not
to efficacy to support one bisphosphonate over the recommended outside of a clinical trial. There is insufficient evidence
other. For each of the guidelines, clinical judgment relating to efficacy to support one bone-modifying agent over another.
should also take into consideration the patient’s
general performance status and overall prognosis.
Recommendation 2: Role of Starting bisphosphonates in women without evidence Starting bone-modifying agents in women without evidence of bone (Unchanged in substance from 2003)
bone-modifying of bone metastases even in the presence of other metastases even in the presence of other extraskeletal metastases is Term changed from bisphosphonates
agents in the extraskeletal metastases is not recommended. This not recommended. This clinical situation has been inadequately to bone-modifying agents.
presence of clinical situation has not been studied using IV studied using IV bisphosphonates or other bone-modifying agents and
extraskeletal bisphosphonates and should be the focus of new should be the focus of new clinical trials.
metastases clinical trials. Starting bisphosphonates in women
with only an abnormal bone scan but without
evidence of bone destruction on radiographs, CT
scans, or MRI is not recommended.
Recommendation 3A: Renal In patients with pre-existing renal disease and a serum In patients with a calculated serum creatinine clearance > 60 mL/min, Addition regarding denosumab. A
safety concerns creatinine Ͻ 3.0 mg/dL (265 ␮mol/L), no change in no change in dosage, infusion time, or interval of pamidronate or change in serum creatinine
dosage, infusion time, or interval of pamidronate or zoledronic acid administration is required. Use of bone-modifying clearance threshold. Last sentence
zoledronic acid is required. Use of these agents among patients with reduced renal function has been of 2003 recommendation taken out.
bisphosphonates among patients with worse incompletely assessed. The packet insert of zoledronic acid Term changed from bisphosphonates
function has been minimally assessed. provides guidance for dosing when baseline serum creatinine to bone-modifying agents.
Infusion times Ͻ 2 hours with pamidronate or Ͻ 15 clearance is > 30 and < 60 mL/min.
minutes with zoledronic acid should be avoided. Infusion times Ͻ 2 hours with pamidronate or Ͻ 15 minutes with
The Panel recommends that serum creatinine should zoledronic acid should be avoided.
be monitored prior to each dose of pamidronate or The Panel recommends that serum creatinine should be monitored prior
zoledronic acid, in accordance with FDA-approved to each dose of pamidronate or zoledronic acid, in accordance with
labeling. Serum calcium, electrolytes, phosphate, FDA-approved labeling. Serum calcium, electrolytes, phosphate,
magnesium, and hematocrit/hemoglobin should magnesium, and hematocrit/hemoglobin should also be monitored
also be monitored regularly but there is no regularly. The risk of hypocalcemia with denosumab dosed at 120
evidence upon which to base a recommendation mg every 4 weeks has not been evaluated in patients with a creat-
for time intervals. inine clearance < 30 mL/min or receiving dialysis. Monitor for
In contrast to multiple myeloma patients, there hypocalcemia in patients with impaired creatinine clearance.
currently are no data to support routine There is no evidence to guide the interval for monitoring serum
assessments for albuminuria in patients with calcium, electrolytes, phosphate, magnesium, and hematocrit/hemoglo-
breast cancer. bin with denosumab, pamidronate, or zoledronic acid.
Recommendation 3B: ONJ N/A ONJ is an uncommon but potentially serious condition associated New recommendation
with the use of bone-modifying agents. The Update Committee
concurs with the revised FDA label for zoledronic acid and
pamidronate and the FDA label for denosumab and recommends
that all patients with cancer receive a dental examination and
necessary preventive dentistry prior to initiating therapy with
inhibitors of osteoclast function unless there are mitigating
factors that preclude the dental assessment. These
recommendations should be observed whenever possible. While
receiving inhibitors of osteoclast function, patients should
maintain optimal oral hygiene and, if possible, avoid invasive
dental procedures that involve manipulation of the jaw bone or
periosteum. Although most cases of ONJ have occurred in
patients treated with IV bisphosphonates and bone-modifying
agents who underwent an invasive dental procedure, cases have
occurred spontaneously and have been reported in patients
treated with other bone-modifying agents, including oral
bisphosphonates and direct osteoclast inhibitors.
(continued on following page)



Table 1. Summary of 2011 Recommendations (continued)
Recommendation Category 2003 Recommendations 2011 Recommendations Change

Recommendation 4: The Panel suggests that once initiated, IV The Panel suggests that once initiated, bone-modifying agents be (Unchanged in substance from 2003)
Optimal duration bisphosphonates be continued until evidence of continued until evidence of substantial decline in a patient’s general Term changed from bisphosphonates
substantial decline in a patient’s general performance status. The Panel stresses that clinical judgment must to bone-modifying agents.
performance status. The Panel stresses that clinical guide what constitutes a substantial decline. There is no evidence
judgment must guide what is a substantial decline. addressing the consequences of stopping bone-modifying agents after
There is no evidence addressing the consequences one or more adverse skeletal-related events.
of stopping bisphosphonates after one or more
adverse skeletal events.
Recommendation 5: For breast cancer patients who have evidence of bone For patients with breast cancer who have evidence of bone destruction on Addition of new bone-modifying agent.
Optimal intervals destruction on plain radiographs, IV pamidronate 90 plain radiographs, denosumab 120 mg subcutaneously every 4 The second-to-last sentence of 2003
between dosing mg delivered over 2 hours or zoledronic acid 4 mg weeks, IV pamidronate 90 mg delivered over 2 hours, or zoledronic recommendation is in
over 15 minutes every 3 to 4 weeks is acid 4 mg over 15 minutes every 3 to 4 weeks is recommended. Recommendation 1 of 2011
recommended. There is insufficient evidence recommendations.
relating to efficacy to support one bisphosphonate The last sentence from 2003
over the other. For each of the guidelines, clinical recommendation applies to all
judgment should also take into consideration the recommendations.
patient’s general performance status and overall
prognosis.
Recommendation 6: Role of The Panel recommends that the current standards of The Panel recommends that the current standards of care for cancer bone Change in timing of pain management.
bone-modifying care for cancer pain management must be applied pain management be applied at the onset of pain, in concert with Term changed from bisphosphonates
agents in pain control throughout bisphosphonate therapy and are the initiation of bone-modifying agent therapy. This is required by to bone-modifying agents.
required by good clinical practice. These standards good clinical practice. The standard of care for pain management
of care for pain management include analgesics, includes the use of nonsteroidal anti-inflammatory agents, opioid and
corticosteroids, interventional procedures, nonopioid analgesics, corticosteroids, adjuvant agents, interventional
nonsteroidal anti-inflammatory agents, systemic procedures, systemic radiopharmaceuticals, local radiation therapy, and
radiopharmaceuticals, and local radiation therapy. surgery. Bone-modifying agents are an adjunctive therapy for
Among other therapeutic options, IV pamidronate cancer-related bone pain control and are not recommended as
or zoledronic acid may be of benefit among women first-line treatment for cancer-related pain. IV pamidronate or
with pain caused by bone metastases to relieve zoledronic acid may be of benefit for patients with pain caused by bone
pain when used concurrently with systemic chemo- metastases and contribute to pain relief when used concurrently with
therapy and/or hormonal therapy, because it was analgesic therapy, systemic chemotherapy, radiation therapy, and/or
associated with a modest pain control benefit in hormonal therapy. Bone-modifying agents have been associated with a
controlled trials. modest pain control benefit in controlled trials.
Recommendation 7: The The use of the biochemical markers to monitor The use of the biochemical markers to monitor bone-modifying agent use (Unchanged in substance from 2003)
role of biochemical bisphosphonate use is not suggested for routine is not recommended for routine care. Term changed from bisphosphonates
markers care. to bone-modifying agents.

NOTE. For each of the recommendations, clinical judgment should also take into consideration the patient’s general performance status, patient preferences,
and overall prognosis. Italicized text indicates minor changes. Bolded text indicates substantive changes.
Abbreviations: IV, intravenous; CT, computed tomography; MRI, magnetic resonance imaging; FDA, US Food and Drug Administration; N/A, not applicable; ONJ,
osteonecrosis of the jaw.

with a creatinine clearance of less than 30 mL/min or receiving dialysis recommends care in line with the FDA-approved labeling. The FDA-
are at a greater risk of severe hypocalcemia than patients with normal approved labeling of denosumab, pamidronate, and zoledronic acid ad-
renal function. vises that patients should maintain good oral hygiene, have preventive
dental examinations before initiating therapy, and avoid invasive dental
Clinical Question 3B procedures whenever possible.12-14 Good oral hygiene includes
What are the ONJ safety concerns of bone-modifying brushing and flossing after meals and use of a fluoride mouth rinse.
agent therapy? The Update Committee, by consensus, suggests that in the setting
Literature update and discussion. This recommendation is new of invasive dental procedures, it is advisable, whenever possible to
to the guideline. ONJ is defined as an area of exposed bone in the delay the starting of therapy with bone-modifying agents until the
maxillofacial or mandibular region that does not heal within 8 weeks initial bone healing process of the tooth socket bone has taken place. If
after identification by a health care provider, in a patient who was an invasive manipulation of the bone underlying the teeth is clinically
receiving or had been exposed to a bisphosphonate administered indicated before starting bone-modifying agent therapy, the Update
orally or IV and had not had radiation therapy to the craniofacial region. Committee consensus opinion is that initiation of bone-modifying
The exposed bone is necrotic. Risk factors for ONJ include both bisphos- agent therapy should be ideally delayed for 14 to 21 days to allow for
phonate type and duration of exposure, with the risk of ONJ increasing wound healing, if the clinical situation permits.
with the higher potency drugs (zoledronic acid) and a longer duration of There were no RCT data to provide support for this recommen-
therapy. The risk for ONJ occurs with denosumab, pamidronate, and dation. The evidence cited for this recommendation includes two
zoledronic acid, whether administered alone or in sequence with other cohort studies, one case-control study, one chart review, two single-
bone-modifying agents. The true incidence, prevalence, and etiology of institution experiences, product labels, and position papers, taskforce
ONJ remain unknown and are the subjects of ongoing investigations. reports, and reviews and/or position papers from other specialty med-
Although direct evidence of the best way to minimize the risk of ical or dental societies. Please refer to the full guideline update for a
ONJ during bone-modifying agent treatment is lacking, the guideline more extensive discussion of ONJ.


Van Poznak et al

Clinical Question 4 ers of bone resorption may have an increased risk for SREs and poor
What is the optimal duration of bone-modifying agent therapy outcomes. Markers of bone formation and bone resorption can be
for patients with metastatic breast cancer? measured in the blood or urine. Osteoclast inhibition can decrease or
Literature update and discussion. This recommendation remains normalize the markers of bone resorption. The association between
unchanged from 2003. There were no new published prospective markers of bone metabolism as a surrogate of osteoclast activity and
clinical trials comparing different durations of bone-modifying agent risk of SREs has been investigated. Although an association has been
therapy. In clinical trials, durations of therapy ranged from 12 weeks in observed, there are no prospective data supporting the use of bio-
an early-phase trial of denosumab to 96 weeks for the bisphosphonates chemical markers for diagnosis, to predict SREs, or to monitor bone-
and up to 34 months in the phase III trial of denosumab. These studies modifying agent therapy.
do not provide data on the impact of either continuing or stopping The guideline reviews data on the following markers:
bone-modifying agent therapy after a defined time course, the rate of N-telopeptide of type I collagen, C-telopeptide of type I collagen,
change in SREs in study groups, or the impact of limited versus bone-specific alkaline phosphatase, osteocalcin, and amino-terminal
sustained versus pulsed use of bisphosphonate therapy. propeptide of type I collagen. The markers were investigated for the
There are no prospective clinical RCT data to support the con- primary purposes of monitoring, predictive value (including pain
tinuation of bone-modifying agent therapy beyond 1 year, especially reduction), and diagnostic accuracy.
for patients who are expected to survive longer than 1 year. In addi- Although there have been several studies showing decreases in bone
tion, the paucity of prospective data addressing long-term toxicities of resorption or formation markers after administration of bone-modifying
bisphosphonates does not permit a balanced evaluation of the risk/ agents, no RCTs on biomarkers in this setting have been published that
benefit profile of any long-term bisphosphonate therapy. used SREs as a primary end point, and the studies’ designs do not permit
conclusions about the clinical utility of these markers. Until the time that
Clinical Question 5 properly defined marker studies demonstrate clinical utility, the use of
What are the best intervals between dosing? biomarkers to guide or monitor bone-modifying agent therapy is not
Literature update and discussion. This recommendation remains recommended outside of a clinical trial.
unchanged from 2003. There was no new evidence to support a
change because most trials have continued using intervals of every 3 to Special Commentary on the Role of Vitamin D
4 weeks. Deficiency and Bone-Modifying Agents
Concerns exist regarding the dosing interval and duration of Although many of the trials of bone-modifying agents have in-
therapy. There are limited data on the local (bone surface) bisphos- cluded supplementation of calcium and vitamin D as part of the
phonate drug concentrations and retention times. These factors are treatment regimen, there are insufficient data to support a recommen-
determined by the cellular status of individual bone surfaces, which is dation for a specific level of supplementation. Optimal concentrations
affected by the rate of bone turnover, which is influenced by prior of vitamin D for bone health have not been established and are likely to
bisphosphonate therapy and the cancer itself. vary at different stages of life and in different clinical settings.
Because of lack of new evidence, the expert consensus of the In the absence of definitive data, it is the Update Committee’s
Update Committee was to continue to support the 2003 recom- expert consensus that if there are no contraindications to calcium and
mendation. The Update Committee recognizes that clinical judg- vitamin D supplementation, then patients with breast cancer receiving
ment may dictate modifications to dose schedules for a variety of bone-modifying agents should receive them at doses and schedules
patient-specific indications. similar to those used in the clinical trials of the bone-modifying agents,
both to support bone health and decrease the risk of osteoclast inhibi-
Clinical Question 6 tion-induced hypocalcemia.
What is the role of bone-modifying agents in control of pain
secondary to bone metastases?
Literature update and discussion. This recommendation remains LIMITATIONS OF RESEARCH AND SUGGESTIONS FOR
unchanged from 2003. Bone-modifying agents are an adjunctive ther- FUTURE RESEARCH
apy for pain control. Pain or the manifestation of an SRE is not
necessary for the initiation of a bone-modifying agent in a patient with Little new data that were published since the 2003 guideline met the
bone metastases from breast cancer. Zoledronic acid, pamidronate, systematic review inclusion criteria to address the majority of clinical
and IV and oral ibandronate have all been shown to reduce pain scores questions in this guideline. New questions have arisen for which there are
(primarily based on the Brief Pain Inventory) and analgesic use in notyetsufficientdatatofullyaddressalloftheclinicallyrelevantquestions.
patients in three RCTs, two cohort studies, and five analyses of data Therefore, further research is needed in many areas addressing the man-
from RCTs reviewed for this guideline update. agement of metastatic breast cancer involving the bone, including the
duration and intervals of delivery of bone-modifying agents. Compo-
Clinical Question 7 nents of a loading strategy at initiation of bisphosphonate therapy and
What is the role of biochemical markers of bone turnover to later stopping or altering the interval are being investigated clinically, but
guide initiation of therapy in patients without a prior skeletal event, presently, there are no data to address the efficacy of such an approach for
predict treatment response, guide adjustments to bone-modifying any outcomes. Future trials may include investigation of pulse bone-
agent therapy, or independently predict future fractures? modifying agent therapy. Additional data may enable the development of
Literature update and discussion. This recommendation remains anindexofriskforSREs,andapatient’sindividualrisk/benefitcalculation
unchanged. Patients with metastatic bone disease and elevated mark- mayguidebone-modifyingagenttherapy.Thereisaneedforclinicaltrials



that explicitly compare different intervals between treatment with bone- those in vulnerable populations. Further discussion of patient-
modifying agents to learn the effects on relevant clinical outcomes such as clinician communication and health disparities is available in the
SREs, time to SRE, pain, or adverse events evaluated in this guideline. full guideline.
Trials specific to whether patients with stage IV breast cancer and
no bone metastases would benefit from initiating bone-modifying
ADDITIONAL RESOURCES
agents are needed. Stratification and analysis by such factors as sex,
estrogen receptor/progesterone receptor status, human epidermal
growth factor receptor 2 status, ethnic and racial status, and whether a The guideline, including evidence tables (Data Supplement), is
given participant has bone-predominant disease versus visceral- available at www.asco.org/guidelines/bisphosbreast, along with a
dominant disease could help identify whether any of these factors are slide set and other resources. Patient information is available there
relevant in selecting the use of bone-modifying agents. In addition, and at www.cancer.net.
more research is needed on denosumab and other new bone-
modifying agents, the role of biomarkers in treatment selection and AUTHORS’ DISCLOSURE OF POTENTIAL
monitoring, the role of calcium and vitamin D supplementation, CONFLICTS OF INTEREST
comparative effectiveness research, and how and when bone-
modifying agents should be integrated with other therapies. Although all authors completed the disclosure declaration, the following
In addition, although progress has been made in the years since the author(s) indicated a financial or other interest that is relevant to the subject
identification of ONJ to characterize and define the toxicity, much re- matter under consideration in this article. Certain relationships marked
with a “U” are those for which no compensation was received; those
search remains to be performed to better determine and ameliorate risk
relationships marked with a “C” were compensated. For a detailed
factors and to offer effective treatment for ONJ associated with bone- description of the disclosure categories, or for more information about
modifying agent therapy for breast cancer. Several ongoing and planned ASCO’s conflict of interest policy, please refer to the Author Disclosure
studiesaregatheringdataonincidence,riskfactors,andtreatmentofONJ. Declaration and the Disclosures of Potential Conflicts of Interest section in
Information for Contributors.
Employment or Leadership: None Consultant or Advisory: Linda
PATIENT-CLINICIAN COMMUNICATION AND Bosserman, Amgen (C), Roche (C); Catherine Van Poznak, Amgen (C);
HEALTH DISPARITIES Gary Yee, Amgen (C), Roche (C) Stock Ownership: None Honoraria:
Linda Bosserman, Abraxis BioScience, Amgen, Roche Research
The Update Committee stresses the importance of communicating Funding: Catherine Van Poznak, Amgen, Novartis Expert Testimony:
risks and benefits of and the rationale expected for using bone- None Other Remuneration: None
modifying agents, including clarifying potential outcomes. The
Update Committee also suggests that clinicians give patients op- AUTHOR CONTRIBUTIONS
portunities to share their expectations of treatment. In addition,
awareness of disparities in access to care should be considered in Administrative support: Sarah Temin
the context of this clinical practice guideline, and health care pro- Manuscript writing: All authors
viders should strive to deliver the highest level of cancer care to Final approval of manuscript: All authors

4. Stopeck AT, Lipton A, Body JJ, et al: Deno- of skeletal complications in patients with advanced
REFERENCES sumab compared with zoledronic acid for the treat- multiple myeloma or breast carcinoma: A random-
ment of bone metastases in patients with advanced ized, double-blind, multicenter, comparative trial.
1a. Hillner BE, Ingle JN, Berenson JR, et al: breast cancer: A randomized, double-blind study. Cancer 98:1735-1744, 2003
American Society of Clinical Oncology Guideline on J Clin Oncol 28:5132-5139, 2010 10. Rosen LS, Gordon D, Tchekmedyian NS, et al:
the Role of Bisphosphonates in Breast Cancer. 5. Tripathy D, Lichinitzer M, Lazarev A, et al: Oral Long-term efficacy and safety of zoledronic acid in
J Clin Oncol 18:1378-1391, 2000 ibandronate for the treatment of metastatic bone the treatment of skeletal metastases in patients with
1b. Hillner BE, Ingle JN, Chlebowski RT, et al: disease in breast cancer: Efficacy and safety results nonsmall cell lung carcinoma and other solid tumors: A
American Society of Clinical Oncology 2003 update from a randomized, double-blind, placebo-controlled randomized, phase III, double-blind, placebo-controlled
on the role of bisphosphonates and bone health trial. Ann Oncol 15:743-750, 2004 trial. Cancer 100:2613-2621, 2004
issues in women with breast cancer. J Clin Oncol 6. Body JJ, Diel IJ, Lichinitzer M, et al: Oral 11. Kohno N, Aogi K, Minami H, et al: Zoledronic
21:4042-4057, 2003 ibandronate reduces the risk of skeletal complications in acid significantly reduces skeletal complications com-
1c. Somerfield MR, Einhaus K, Hagerty KL, et al: breast cancer patients with metastatic bone disease: pared with placebo in Japanese women with bone
American Society of Clinical Oncology clinical prac- Results from two randomized, placebo-controlled phase metastases from breast cancer: A randomized, placebo-
tice guidelines: Opportunities and challenges. J Clin III studies. Br J Cancer 90:1133-1137, 2004 controlled trial. J Clin Oncol 23:3314-3321, 2005
Oncol 26:4022-4026, 2008 7. Heras P, Kritikos K, Hatzopoulos A, et al: 12. US Food and Drug Administration: FDA-
2. Lipton A, Steger GG, Figueroa J, et al: Ex- Efficacy of ibandronate for the treatment of skeletal approved label: Zoledronic acid packet insert. http://
tended efficacy and safety of denosumab in breast events in patients with metastatic breast cancer. www.accessdata.fda.gov/drugsatfda_docs/label/2009/
cancer patients with bone metastases not receiving Eur J Cancer Care (Engl) 18:653-656, 2009 021223s018lbl.pdf
prior bisphosphonate therapy. Clin Cancer Res 14: 8. Body JJ, Diel IJ, Lichinitser MR, et al: Intrave- 13. US Food and Drug Administration: FDA-approved
6690-6696, 2008 nous ibandronate reduces the incidence of skeletal label: Xgeva (denosumab). http://www.accessdata
3. Fizazi K, Lipton A, Mariette X, et al: Random- complications in patients with breast cancer and .fda.gov/drugsatfda_docs/label/2010/125320s007lbl.pdf
ized phase II trial of denosumab in patients with bone metastases. Ann Oncol 14:1399-1405, 2003 14. US Food and Drug Administration: FDA-approved
bone metastases from prostate cancer, breast can- 9. Rosen LS, Gordon D, Kaminski M, et al: Long- label: Aredia, pamidronate disodium packet insert. http://
cer, or other neoplasms after intravenous bisphos- term efficacy and safety of zoledronic acid com- www.accessdata.fda.gov/drugsatfda_docs/label/2008/
phonates. J Clin Oncol 27:1564-1571, 2009 pared with pamidronate disodium in the treatment 020036s035lbl.pdf

■ ■ ■


cancer de seno metastasico

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (9)

Similar to cancer de seno metastasico

Similar to cancer de seno metastasico (20)

Recently uploaded

Recently uploaded (20)

cancer de seno metastasico